Clinical Practice Guidelines

Intravenous access - Peripheral

    • See also:      Procedural Pain Management guideline

      Background

      • 'Needles' are often the most feared painful procedure in children.
      • Always justify the need for the procedure.
      • Combine with blood sampling if needed.
      • Explain the procedure to the child and parents and obtain verbal consent.

      Selection of Intravenous ( IV ) access

      The following guidelines should be considered when referring patient for IV access:

      Duration IV access required   

      Selection of catheter

      < 7 days  Peripheral IV access
      7-14 days or
      failed peripheral IV attempts 
      PICC (peripherally inserted central catheter) or Percutaneous CVAD
      > 14 days   PICC or resite percutaneous CVAD or consider Surgical Line 
      Long term (> 30 days) Surgical CVAD (Hickman/Broviac or Ports)

      Preparation

      The patient

      Infants <3 months:

      • Oral sucrose with a pacifier should be used (see Analgesia guideline) or encourage mother to feed infant during procedure.
      • Give parent or carer option to hold infant during procedure & employ multisensory stimulation

      Older infants & children:

      • Apply topical anaesthetic creams in advance of procedure whenever possible:
        • AnGel™: 45 minutes
        • EMLA™: 60 minutes
      • Explain what you are doing -needs discussion
      • Use Play Therapy, distraction, relaxation and other coping skills, see Comfort Kids techniques
      • Consider nitrous oxide for anxious children
      Setting & equipment
      • Whenever possible, procedures should be performed AWAY from the bedside (i.e. in treatment rooms)
      • Get helpers - you will need at least one other staff-member
      • Adequate lighting

      Have equipment ready before the child enters the room:

      • Dressing pack
      • Skin preparation: alcoholic chlorhexidine
      • IV cannula
      • Sterile syringe & blood tubes (for blood)
      • Syringe - with normal saline
      • 3-way tap connector and tubing, primed with N-saline
      • Sterile IV dressing (eg. Tegaderm™)
      • Taping, splint &  Crepe bandage
       Yourself 

      Procedure

      Sites

      • Look carefully with a torniquet for the most suitable vein & remember that in paediatric patients the best vein may not necessarily be palpable.
      • Dorsum of the non-dominant hand is preferred - the vein running between the 4th and 5th metacarpals is most frequently used.
      • In addition to the usual sites in adults, commonly used sites in children include the volar aspect of the forearm, dorsum of the foot & the great saphenous vein at ankle.
      • Consider practicalities of splinting (e.g. elbow, foot in a mobile child).
      • Scalp veins should only be used by more experienced doctors (shaved scalp hair re-grows very slowly).

      Technique

      Holding

      • Ask the assistant to stabilise limb by holding joint above & joint below if necessary.
      • If applying tourniquet, be careful of pinching skin or compressing artery.
      • In infants when accessing the hand, grasp as shown; this achieves both immobilisation and tourniquet ( Fig 1)

      Inserting the cannula

      • Decontaminate skin with alcohol wipe or alcoholic chlorhexidine 0.5% & leave to dry. Use 'no-touch' technique for insertion after decontamination.
      • Insert just distal to and along the line of the vein
      • Angle at 10-15° ( Fig 2)
      • Advance needle & cannula slowly
      • A 'flash back' of blood may not occur for small veins.
      • Once in vein, advance the needle & cannula SLOWLY a further 1-2mm along the line of the vein before advancing cannula off needle.
      • Secure the hub of the cannula at the skin entry point either by holding it down or asking the assistant to place tape across.
       shallow angle.jpg  
      Figure 1: holding an infant's hand  Figure 2: shallow angle of insertion  

      Taking blood samples

      • For 24G cannulae, it is often easier to let blood drip passively into collection bottles (Fig 3)
      • When taking blood for culture or gas from small cannulae, aspirate blood from the hub of the cannula using a blunt 'drawing up' needle and syringe (Fig 4)
      • For larger cannulae, a syringe can be used to aspirate blood.
      shallow angle.jpg shallow angle.jpg  
       Figure 3: passive blood collection for infants

      Fig 4: aspirating blood for culture or gas

       

      Strapping

      • Connect the saline-filled 3-way connector to the end of the cannula by screwing it firmly on.Flush the connector tubing with more saline to confirm intravenous placement.
      • In younger children use inverted cross-over straps and another tape over the top (Fig 5)
      • Consider placing a small piece of cotton wool ball or gauze underneath the hub of the cannula to prevent pressure areas (Fig 5)
      • Place an adhesive clear plastic dressing on top (Fig 6)
      • Tapes should secure the limb proximal and distal to the cannula (keeping thumb free) but not too tightly (Fig 7)
      • Wrap the whole distal extremity in Tubular-Fast (Surgifix).. In very young children, give consideration to bandaging the other hand as well to prevent them from removing the cannula.
      shallow angle.jpg shallow angle.jpg  
      Fig 5: pad under cannula to prevent pressure areas. IV site should remain visible   Fig 6: secure with tegadermTM so that IV site is visible  

      shallow angle.jpg

      Fig 7: Strap so that joint is immobilised, but avoiding tapes being too tight

      Post-Procedure Care

      • Running a 'drug line' (3-5ml/hr of N Saline) through the cannula may keep it patent for a longer period of time.
      • Inspect insertion site for complications (tenderness, blockage, inflammation, discharge) hourly - check the other hand if it has also been bandaged.. 
      • Unless complications develop, the peripheral IV should remain insitu until IV treatment complete.

      Trans-illumination

      • Application a COLD light directly to the skin in a darkened room can be helpful in finding veins in neonates and infants.
      • Only cold lights (usually fiber-optic sources) should be used. Normal torches can burn the skin and should never be used.
      • Trans-illumination adds a layer of complexity to IV insertion as the operator has to hold a light to the skin, position the site and insert the cannula.

      Unsuccessful insertion

      • Only 2 attempts should be made to insert a cannula and multiple(s) unsuccessful attempts should be avoided.
      • See flow chart
      iv insertion
    • See video